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  1. eCQM Issue Tracker
  2. CQM-5434

BMI CMS 69V10

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    • Icon: EC eCQMs EC eCQMs
    • Resolution: Answered
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    • Hannah Olson
    • 7208656074
    • Orthopedic Centers of Colorado, LLC
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      ​​Thank you for your inquiry regarding CMS69v10: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan. We are aware that a discrepancy exists between the numerator statement provided in the header and the CQL. Since the header is only meant to provide a written narrative of the measure logic, please refer to the measure logic itself as the source of truth regarding the numerator. A Known Issue, posted in November 2021 provides additional details related to this misalignment present in both CMS69v9 and CMS69v10 (https://oncprojectracking.healthit.gov/support/browse/EKI-13).

      Specific to CMS69v10, CMS published guidance, posted on the eCQI Resource Center, to support measure implementation for 2022 (https://ecqi.healthit.gov/sites/default/files/CMS69v10_BMI_Measure_Guidance.pdf).

      Changes to the timing anchors in CMS69v9 (PY2021), specific to the clinical actions included in the numerator, require a follow-up intervention be 12 months on or after the most recent high/low BMI. As a result, regardless of how many times the patient is screened during the measurement period, the most recent BMI is used to evaluate the measure and the BMI has to be documented during the qualifying encounter or within the 12 months prior. However, the follow-up plan/intervention must be documented during the qualifying encounter or within 12 months after the most recent documented BMI. The logic effectively requires providers to order a follow-up plan/intervention for a patient at the same time or after the most recent high/low BMI value.
      Show
      ​​Thank you for your inquiry regarding CMS69v10: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan. We are aware that a discrepancy exists between the numerator statement provided in the header and the CQL. Since the header is only meant to provide a written narrative of the measure logic, please refer to the measure logic itself as the source of truth regarding the numerator. A Known Issue, posted in November 2021 provides additional details related to this misalignment present in both CMS69v9 and CMS69v10 ( https://oncprojectracking.healthit.gov/support/browse/EKI-13 ). Specific to CMS69v10, CMS published guidance, posted on the eCQI Resource Center, to support measure implementation for 2022 ( https://ecqi.healthit.gov/sites/default/files/CMS69v10_BMI_Measure_Guidance.pdf ). Changes to the timing anchors in CMS69v9 (PY2021), specific to the clinical actions included in the numerator, require a follow-up intervention be 12 months on or after the most recent high/low BMI. As a result, regardless of how many times the patient is screened during the measurement period, the most recent BMI is used to evaluate the measure and the BMI has to be documented during the qualifying encounter or within the 12 months prior. However, the follow-up plan/intervention must be documented during the qualifying encounter or within 12 months after the most recent documented BMI. The logic effectively requires providers to order a follow-up plan/intervention for a patient at the same time or after the most recent high/low BMI value.
    • CMS0069v10
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      Based on the "most recent" logic from our EMR, we are being required to counsel or follow up with the patient at every specialty visit where we take vitals. This is a burden to the patient, but also from a documentation standpoint for our providers. Is this measure intended to be requiring documentation every visit?
      Show
      Based on the "most recent" logic from our EMR, we are being required to counsel or follow up with the patient at every specialty visit where we take vitals. This is a burden to the patient, but also from a documentation standpoint for our providers. Is this measure intended to be requiring documentation every visit?

      Hello -

       

      Our EMR is requiring that in order to meet the measure expectations from CMS 69v10, that every time we enter height and weight on a patient, and their BMI Is outside of a normal range, that we are required to document our follow up plan for the patient.  Our interpretation of the measure was that we needed to do this once within the performance period. I've highlighted the section that led us to believe this.

       

       

      Numerator: Patients with a documented BMI during the encounter or during the previous twelve months,

      AND when the BMI is outside of normal parameters, a follow-up plan is documented during the

      encounter or during the previous twelve months of the current encounter

       

      Some of the confusion is stemming from the phrase that the follow up must be on same day or after most recent BMI. Can you help us to understand if we need to do this for every visit where we take the patient's height and weight (given the patient's BMI is outside of the normal range)?

       

      Thanks,

      Hannah

            edave Mathematica EC eCQM Team
            hannah.olson Hannah Olson (Inactive)
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